1
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Park SY, Kang T, Jeong WK, Song JE. Prevalence, Risk Factors, and Postoperative Infection Rates of Blood Transfusion in Lumbar Spinal Fusion Surgery: A Nationwide Population-Based Study. J Clin Med 2024; 13:4867. [PMID: 39201008 PMCID: PMC11355348 DOI: 10.3390/jcm13164867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Revised: 08/12/2024] [Accepted: 08/15/2024] [Indexed: 09/02/2024] Open
Abstract
Study Design: Retrospective cohort study. Objectives: Effects of blood loss that requires blood transfusion after lumbar spinal fusion remain an important issue. Blood transfusions are used commonly in cases of significant blood loss in lumbar spinal fusion but are associated with adverse effects. The objective was to assess the rate of blood transfusion and the associated risk after lumbar spinal fusion from 2013 to 2018. Methods: In this nationwide population-based cohort study, the Korean Health Insurance Review and Assessment Service database was reviewed retrospectively from 2013 to 2018. Data were extracted from patients who underwent lumbar spinal fusion without history of lumbar spinal surgery in the preceding year. The primary outcome was the rate of blood transfusion within 1 week of surgery. In addition, the risk factors for blood transfusion and the rate of postoperative infection were evaluated. Results: A total of 188,581 patients underwent lumbar spinal fusion between 2013 and 2018. A significant decline in blood transfusions was observed during the study period (56.38-47.51%). The presence of comorbidities was associated with an increased risk of blood transfusion. Patients who underwent the posterior approach were more likely to receive blood transfusion than patients who underwent the anterior or anterior and posterior approach. Receiving blood transfusion was associated with postoperative infection. Conclusions: In the present study, the prevalence, risk factors, and postoperative infection rates associated with blood transfusion in lumbar spinal fusion were identified. Spine surgeons should consider these risk factors in patients at high risk of blood transfusion.
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Affiliation(s)
- Si Young Park
- Department of Orthopedics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea;
| | - Taewook Kang
- Department of Spine Surgery, Cheil Orthopedic Hospital, Seoul 06075, Republic of Korea
| | - Woong Kyo Jeong
- Department of Orthopedics, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea;
| | - Ji Eun Song
- Department of Biostatistics, Korea University College of Medicine, Seoul 02841, Republic of Korea;
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2
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Kargar-soleimanabad S, khormali A, Godazandeh F, Najafi S. Effect of oral tranexamic acid on postoperative bleeding in spinal surgery: a randomized controlled trial. Ann Med Surg (Lond) 2024; 86:4483-4487. [PMID: 39118779 PMCID: PMC11305740 DOI: 10.1097/ms9.0000000000001820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/02/2024] [Indexed: 08/10/2024] Open
Abstract
Background and objective This study aimed to investigate the effect of oral administration of tranexamic acid (TXA) on reducing intraoperative bleeding during spinal surgeries. Method The study was a single-center, double-blind, randomized, placebo-controlled clinical trial. Participants were individuals over 20 years old who underwent spinal surgery. Patients received 1.5 g of TXA orally, 2 h before surgery. Intraoperative bleeding volume, blood volume in the drain after surgery, length of hospital stays after surgery, incidence of nausea or vomiting, decrease in hemoglobin (Hb) level, and postoperative coagulation test results were evaluated in each group. Results In this study, patients were assigned to each study group based on inclusion and exclusion criteria. The mean age of patients was 69.6±6.47 years, and 65% were male. There was no significant difference in age, sex, pre and postoperative Hb levels, prothrombin time (PT), or international normalized ratio (INR) between the study groups. Intraoperative bleeding volume and blood volume in the drain after surgery were significantly lower in the TXA group. Additionally, the length of hospital stay after surgery was significantly shorter in the TXA group. The incidence of nausea or vomiting was significantly higher in the TXA group. Furthermore, postoperative partial thromboplastin time (PTT) was significantly higher in the TXA group compared to the placebo group. Conclusion Oral administration of TXA before spinal surgery leads to a significant reduction in intraoperative and postoperative bleeding without significant adverse effects and also reduces the length of hospital stay.
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Affiliation(s)
| | | | - Farnaz Godazandeh
- Department of Radiology and Nuclear Medicine, School of Medicine, Sari Imam Khomeini Hospital
| | - Sajjad Najafi
- Department of Neurosurgery, Mazandaran University of Medical Sciences, Sari, Iran
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3
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Mimura T, Ikegami S, Uehara M, Oba H, Hatakenaka T, Kamanaka T, Miyaoka Y, Kurogochi D, Fukuzawa T, Koseki M, Takahashi J. Real-World Effectiveness of Gelatin-Thrombin Matrix Sealant on Blood Loss in Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Spinal Fusion: An Interrupted Time Series Study. Spine (Phila Pa 1976) 2024; 49:547-552. [PMID: 37014827 DOI: 10.1097/brs.0000000000004666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 02/05/2023] [Indexed: 04/05/2023]
Abstract
STUDY DESIGN Retrospective cohort study with interrupted time series analysis. OBJECTIVE To examine the clinical effectiveness of gelatin-thrombin matrix sealant (GTMS) on blood loss reduction after adolescent idiopathic scoliosis (AIS) surgery. SUMMARY OF BACKGROUND DATA The real-world effectiveness of GTMS on blood loss reduction in AIS surgery has not been determined. PATIENTS AND METHODS The medical records of patients receiving AIS surgery were retrospectively collected during a period before GTMS approval at our institution (January 22, 2010-January 21, 2015) as well as during a postintroduction period (January 22, 2015-January 22, 2020). The primary outcomes were intraoperative blood loss, drain output over 24 hours, and total blood loss (intraoperative blood loss + drain output over 24 h). Interrupted time series analysis using a segmented linear regression model was used to estimate the effect of GTMS on blood loss reduction. RESULTS A total of 179 AIS patients [mean age (range): 15.4 (11-30) yr; 159 females and 20 males; 63 preintroduction patients and 116 postintroduction patients] were included. After its introduction, GTMS was used in 40% of cases. Interrupted time series analysis revealed changes of -340 mL (95% CI: -649 to -31, P = 0.03) for intraoperative blood loss, -35 mL (95% CI: -124 to 55, P = 0.44) for drain output over 24 hours, and -375 mL (95% CI: -698 to -51, P = 0.02) for total blood loss. CONCLUSIONS The availability of GTMS was significantly associated with reduced intraoperative and total blood loss in AIS surgery. GTMS use as needed is recommended to control intraoperative bleeding in the setting of AIS surgery. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Tetsuhiko Mimura
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shota Ikegami
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masashi Uehara
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroki Oba
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Terue Hatakenaka
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takayuki Kamanaka
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yoshinari Miyaoka
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Daisuke Kurogochi
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takuma Fukuzawa
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Michihiko Koseki
- Textile Science and Technology, Shinshu University, Nagano, Japan
| | - Jun Takahashi
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
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4
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Prasad N, Jain A, Bronheim RS, Marrache M, Njoku DB, Sponseller PD. Elevated preoperative blood pressure and its relationship to intraoperative mean arterial pressure and blood loss in posterior spinal fusion for adolescent idiopathic scoliosis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:339-345. [PMID: 37498351 PMCID: PMC11070198 DOI: 10.1007/s00590-023-03652-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/15/2023] [Indexed: 07/28/2023]
Abstract
PURPOSE The relationship between preoperative blood pressure (BP) and intraoperative mean arterial pressure (MAP) and estimated blood loss (EBL) in pediatric spine surgery is currently unknown. The objectives of this study were to determine if elevated preoperative BP is associated with elevated intraoperative MAP, EBL, and percentage estimated blood volume (EBV) lost, and to determine if intraoperative MAP is associated with percentage of EBV lost during posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). METHODS This is a retrospective cohort analysis of 209 patients undergoing PSF for AIS between 2016 and 2019 by a single surgeon. Data extracted included demographic characteristics, preoperative systolic and diastolic BP, continuous intraoperative MAP measured by arterial line, EBL, radiographic, and surgical characteristics. Time points of interest for MAP included incision and exposure. Elevated BP was defined as > 1 standard deviation above the mean BP of patients included in the study, and elevated MAP was defined as > 65 mmHg. RESULTS Elevated preoperative systolic BP was associated with elevated MAP at incision (p = 0.002). Patients with elevated preoperative diastolic BP had significantly higher MAP at exposure and throughout the procedure (p = 0.04). MAP > 65 at incision was associated with a 5% increase in EBV lost (p < 0.001). CONCLUSIONS Patients with elevated preoperative BP parameters have increased MAPs at incision, exposure, and throughout surgery. Elevated MAP at incision is associated with an increased percentage of EBV lost in a small number of patients undergoing PSF for AIS.
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Affiliation(s)
- Niyathi Prasad
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, 21287, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, 21287, USA
| | - Rachel S Bronheim
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, 21287, USA.
| | - Majd Marrache
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, 21287, USA
| | - Dolores B Njoku
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Anesthesiology and Pain Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, 21287, USA
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5
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Fernandes P, Flores I, Soares do Brito J. Benefits of Best Practice Guidelines in Spine Fusion: Comparable Correction in AIS with Higher Density and Fewer Complications. Healthcare (Basel) 2023; 11:healthcare11111566. [PMID: 37297705 DOI: 10.3390/healthcare11111566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/05/2023] [Accepted: 05/19/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND There is significant variability in surgeons' instrumentation patterns for adolescent idiopathic scoliosis surgery. Implant density and costs are difficult to correlate with deformity correction, safety, and quality of life measures. MATERIALS AND METHODS Two groups of postoperative adolescents were compared based on exposure to a best practice guidelines program (BPGP) introduced to decrease complications. Hybrid and stainless steel constructs were dropped, and posterior-based osteotomies, screws, and implant density were increased to 66.8 ± 12.03 vs. 57.5 ± 16.7% (p < 0.001). The evaluated outcomes were: initial and final correction, rate of correction loss, complications, OR returns, and SRS-22 scores (minimum two-year follow-up). RESULTS 34 patients were operated on before BPGP and 48 after. The samples were comparable, with the exceptions of a higher density and longer operative times after BPGP. Initial and final corrections before BPGP were 67.9° ± 22.9 and 64.6° ± 23.7; after BPGP, the corrections were 70.6° ± 17.4 and 66.5° ± 14.9 (sd). A regression analysis did not show a relation between the number of implants and postoperative correction (beta = -0.116, p = 0.307), final correction (beta = -0.065, p = 0.578), or loss of correction (beta= -0.137, p = 0.246). Considering screw constructs only (n = 63), a regression model controlled for flexibility continued to show a slight negative effect of density on initial correction (b = -0.274; p = 0.019). Only with major curve concavity was density relevant in initial correction (b = 0.293; p = 0.038), with significance at 95% not being achieved for final correction despite a similar beta (b = 0.263; p = 0.069). Complications and OR returns dropped from 25.6% to 4.2%. Despite this, no difference was found in SRS-22 (4.30 ± 0.432 vs. 4.42 ± 0.39; sd) or subdomain scores pre- and post-program. FINDINGS Although it appears counterintuitive that higher density, osteotomies, and operative time may lead to fewer complications, the study shows the value of best practice guidelines in spinal fusions. It also shows that a 66% implant density leads to better safety and efficacy, avoiding higher costs.
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Affiliation(s)
- Pedro Fernandes
- Centro Hospitalar Universitário Lisboa Norte, Orthopaedics Department, Avenida Professor Egas Moniz, 1649-035 Lisboa, Portugal
- Clínica Universitária de Ortopedia, Faculdade de Medicina da Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-035 Lisboa, Portugal
| | - Isabel Flores
- ISCTE Instituto Universitário de Lisboa, 1649-026, Lisboa, Portugal
| | - Joaquim Soares do Brito
- Centro Hospitalar Universitário Lisboa Norte, Orthopaedics Department, Avenida Professor Egas Moniz, 1649-035 Lisboa, Portugal
- Clínica Universitária de Ortopedia, Faculdade de Medicina da Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-035 Lisboa, Portugal
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6
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Schupper AJ, Kaufman M, Reidler JS, Arginteanu MS, Moore FM, Steinberger A, Syed ON, Yao KC, Gologorsky Y. Spinal deformity surgery in patients for whom blood transfusion is not an option: a single-center experience. J Neurosurg Spine 2023; 38:348-356. [PMID: 36866794 DOI: 10.3171/2022.11.spine221061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Spinal deformity surgery is associated with significant blood loss, often requiring the transfusion of blood and/or blood products. For patients declining blood or blood products, even in the face of life-threatening blood loss, spinal deformity surgery has been associated with high rates of morbidity and mortality. For these reasons, patients for whom blood transfusion is not an option have historically been denied spinal deformity surgery. METHODS The authors retrospectively reviewed a prospectively collected data set. All patients declining blood transfusion who underwent spinal deformity surgery at a single institution between January 2002 and September 2021 were identified. Demographics collected included age, sex, diagnosis, details of any prior surgery, and medical comorbidities. Perioperative variables included levels decompressed and instrumented, estimated blood loss, blood conservation techniques used, length of surgery, length of hospital stay, and complications from surgery. Radiographic measurements included, where appropriate, sagittal vertical axis correction, Cobb angle correction, and regional angular correction. RESULTS Spinal deformity surgery was performed in 31 patients (18 male, 13 female) over 37 admissions. The median age at surgery was 41.2 years (range 10.9-70.1 years), and 64.5% had significant medical comorbidities. A median of 9 levels (range 5-16 levels) were instrumented per surgery, and the median estimated blood loss was 800 mL (range 200-3000 mL). Posterior column osteotomies were performed in all surgeries, and pedicle subtraction osteotomies in 6 cases. Multiple blood conservation techniques were used in all patients. Preoperative erythropoietin was administered prior to 23 surgeries, intraoperative cell salvage was used in all, acute normovolemic hemodilution was performed in 20, and perioperative administration of antifibrinolytic agents was performed in 28 surgeries. No allogenic blood transfusions were administered. Surgery was staged intentionally in 5 cases, and there was 1 unintended staging due to intraoperative blood loss from a vascular injury. There was 1 readmission for a pulmonary embolus. There were 2 minor postoperative complications. The median length of stay was 6 days (range 3-28 days). Deformity correction and the goals of surgery were achieved in all patients. Two patients underwent revision surgery during the follow-up period: one for pseudarthrosis and the other for proximal junctional kyphosis. CONCLUSIONS With proper preoperative planning and judicious use of blood conservation techniques, spinal deformity surgery may be performed safely in patients for whom blood transfusion is not an option. The same techniques can be applied widely to the general population in order to minimize blood loss and the need for allogeneic blood transfusion.
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Affiliation(s)
| | - Margit Kaufman
- and Departments of2Anesthesiology and Critical Care Medicine
| | - Jay S Reidler
- 3Orthopaedic Surgery, Mount Sinai Health System, New York, New York
- 4Orthopaedic Surgery, and
| | - Marc S Arginteanu
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Frank M Moore
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Alfred Steinberger
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Omar N Syed
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Kevin C Yao
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Yakov Gologorsky
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
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7
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Uchida S, Kinoshita H, Takekawa D, Saito J, Hirota K. Acute normovolemic hemodilution reduced the frequency and amount of perioperative allogeneic blood transfusion in pediatric and adolescent scoliosis surgery: a retrospective observational study. J Anesth 2022; 36:484-492. [PMID: 35676440 DOI: 10.1007/s00540-022-03078-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of the present study is to investigate whether acute normovolemic hemodilution (ANH) can reduce the frequency and amount of perioperative allogeneic blood transfusion (ABT) (intraoperative ABT and postoperative ABT until discharge from the hospital) in pediatric and adolescent scoliosis surgery. METHODS This single-center, retrospective, observational study included the perioperative data of 147 patients who were 18 years old or younger and underwent scoliosis surgery. Patients were divided into groups according to whether they received ANH: i.e., an ANH group and control group. Propensity-score-adjusted multivariable logistic regression analysis was performed to determine whether ANH can reduce the frequency of perioperative ABT. RESULTS A total of 125 patients were analyzed, 95 and 30 in the ANH and control group, respectively. The intraoperative/postoperative ABT frequency was significantly lower in the ANH group than in the control group (17.9% vs. 36.7%, p = 0.044). The amount of ABT [median (IQR): 0 (0, 0) mL/kg vs. 0 (0, 16.3) mL/kg, p = 0.033] was also significantly lower in the ANH group than in the control group. Propensity-score-adjusted multivariable logistic regression analysis indicated that ANH use [odds ratio: 0.15; 95% confidence interval: 0.03, 0.77; p = 0.023)] was associated with a lower risk of ABT after adjusting for intraoperative blood loss and duration of surgery. CONCLUSION ANH use can reduce the frequency and amount of perioperative ABT in pediatric and adolescent scoliosis surgery.
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Affiliation(s)
- Satoshi Uchida
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan
| | - Hirotaka Kinoshita
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan
| | - Daiki Takekawa
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan.
| | - Junichi Saito
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan
| | - Kazuyoshi Hirota
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan
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8
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Alhammoud A, Alborno Y, Baco AM, Othman YA, Ogura Y, Steinhaus M, Sheha ED, Qureshi SA. Minimally Invasive Scoliosis Surgery Is a Feasible Option for Management of Idiopathic Scoliosis and Has Equivalent Outcomes to Open Surgery: A Meta-Analysis. Global Spine J 2022; 12:483-492. [PMID: 33557618 PMCID: PMC9121169 DOI: 10.1177/2192568220988267] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
STUDY DESIGN Meta-analysis. OBJECTIVE To compare outcomes between minimally invasive scoliosis surgery (MISS) and traditional posterior instrumentation and fusion in the correction of adolescent idiopathic scoliosis (AIS). METHODS A literature search was performed using MEDLINE, PubMed, EMBASE, Google scholar and Cochrane databases, including studies reporting outcomes for both MISS and open correction of AIS. Study details, demographics, and outcomes, including curve correction, estimated blood loss (EBL), operative time, postoperative pain, length of stay (LOS), and complications, were collected and analyzed. RESULTS A total of 4 studies met the selection criteria and were included in the analysis, totaling 107 patients (42 MIS and 65 open) with a mean age of 16 years. Overall there was no difference in curve correction between MISS (73.2%) and open (76.7%) cohorts. EBL was significantly lower in the MISS (271 ml) compared to the open (527 ml) group, but operative time was significantly longer (380 min for MISS versus 302 min for open). There were no significant differences between the approaches in pain, LOS, complications, or reoperations. CONCLUSION MISS was associated with less blood loss but longer operative times compared to traditional open fusion for AIS. There was no difference in curve correction, postoperative pain, LOS, or complications/reoperations. While MISS has emerged as a feasible option for the surgical management of AIS, further research is warranted to compare these 2 approaches.
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Affiliation(s)
- Abduljabbar Alhammoud
- Hamad Medical Corporation, Doha,
Qatar,Kaiser Permanente Oakland Medical
Center, Oakland, CA, USA
| | | | | | | | - Yoji Ogura
- Japanese Red Cross Shizuoka Hospital,
Shizuoka, Japan
| | | | - Evan D. Sheha
- Hospital for Special Surgery, New York,
NY, USA,Weill Cornell Medical College, New York,
NY, USA
| | - Sheeraz A. Qureshi
- Hospital for Special Surgery, New York,
NY, USA,Weill Cornell Medical College, New York,
NY, USA,Sheeraz A. Qureshi, Hospital for Special
Surgery, 535 E. 70th St., New York, NY 10021, USA.
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9
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Barrie U, Youssef CA, Pernik MN, Adeyemo E, Elguindy M, Johnson ZD, Ahmadieh TYE, Akbik OS, Bagley CA, Aoun SG. Transfusion guidelines in adult spine surgery: a systematic review and critical summary of currently available evidence. Spine J 2022; 22:238-248. [PMID: 34339886 DOI: 10.1016/j.spinee.2021.07.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/09/2021] [Accepted: 07/26/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Red blood cell transfusion can be associated with complications in medical and surgical patients. Acute anemia in ambulatory patients undergoing surgery can also impede wound healing and independent self-care. Current transfusion threshold guidelines are still based on evidence derived from critically-ill intensive care unit medical patients and may not apply to spine surgery candidates. PURPOSE We aimed to provide the reader with a synthesis of the best available evidence to recommend transfusion trigger thresholds and guidelines in adult patients undergoing spine surgery. STUDY DESIGN/SETTING This is a systematic review. OUTCOME MEASURES Physiological measure: Blood transfusion thresholds and associated posttransfusion complications (morbidity, mortality, length of stay, infections, etc) of the published articles. PATIENT SAMPLE Adult spine surgery patients. METHODS A systematic review of the literature using the PubMed, Google Scholar, and Web of Science electronic databases was made according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Focus was set on papers discussing thresholds for blood transfusion in adult surgical spine patients, as well as complications associated with transfusion after acute surgical blood loss in the operating room or postoperative period. Publications discussing pediatric cases, blood type analyses, blood loss prevention strategies and protocols, systematic reviews and letters to the editor were excluded. RESULTS A total of 22 articles fitting our search criteria were reviewed. Patients who received blood transfusion in these studies were older, of female gender, had more severe comorbidities except for smoking, and had prolonged surgical time. Blood transfusion was associated with multiple adverse postoperative complications, including a higher rate of superficial or deep surgical site infections, sepsis, urinary and pulmonary infections, cardiovascular complications, return to the operating room, and increased postoperative length of stay and 30 day readmission. Analysis of transfusion thresholds from these studies showed that a pre-operative hemoglobin (Hb) of > 13 g/dL, and an intraoperative and post-operative Hb nadir above 9 and 8 g/dL, respectively, were associated with better outcomes and fewer wound infections than lower thresholds (Level B Class III). Additionally, it was generally recommended to transfuse autologous blood that was < 28 days old, if possible, with a limit of 2 to 3 units to minimize patient morbidity and mortality. CONCLUSIONS Blood transfusion thresholds in surgical patients may be specialty-specific and different than those used for critically-ill medical patients. For adult spine surgery patients, red blood cell transfusion should be avoided if Hb numbers remain > 9 and 8 g/dL in the intraoperative and direct post-operative periods, respectively.
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Affiliation(s)
- Umaru Barrie
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA.
| | - Carl A Youssef
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA
| | - Mark N Pernik
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA
| | - Emmanuel Adeyemo
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA
| | - Mahmoud Elguindy
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA
| | - Zachary D Johnson
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA
| | - Tarek Y El Ahmadieh
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA
| | - Omar S Akbik
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA; University of Texas Southwestern Medical Center, Spine Center, Dallas, TX-75235, USA5
| | - Carlos A Bagley
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA; University of Texas Southwestern Medical Center, Department of Orthopedic Surgery, Dallas, TX-75235, USA; University of Texas Southwestern Medical Center, Spine Center, Dallas, TX-75235, USA5
| | - Salah G Aoun
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA; University of Texas Southwestern Medical Center, Spine Center, Dallas, TX-75235, USA5
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10
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Baroun-Agob L, Liew S, Gabbe B. Outcomes of surgical site infections following spinal column trauma. ANZ J Surg 2021; 91:647-652. [PMID: 33543581 DOI: 10.1111/ans.16578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 10/05/2020] [Accepted: 12/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Surgical site infections (SSI) are an undesirable outcome of spinal surgery for both the patient and healthcare system. To date, few studies have investigated the impact of SSI on patient-reported and clinical outcomes. Sepsis and readmission are potential sequelae of SSI, with sepsis potentially being life threatening. This study aimed to assess the association between SSI and patient outcomes in a spinal trauma cohort. METHODS Adult (16+ years) patients who underwent emergency spinal surgery due to trauma between January 2010 and December 2016 at a major trauma centre in Melbourne, Australia, were identified through the Victorian Orthopaedic Trauma Outcomes Registry. The presence of an SSI was abstracted from the electronic medical record and outcomes were compared between patients with and without an SSI. Clinical outcomes were obtained from the medical record, and patient-reported outcomes at 6 and 12 months were obtained from the Victorian Orthopaedic Trauma Outcomes Registry. Chi-squared tests were used to compare patient outcomes between groups. RESULTS Of the 458 included patients, 26 (5.7%) developed an SSI. Patient-reported outcomes at 6 and 12 months were not different between the groups. An SSI was associated with sepsis (χ2 1 = 24.20, P < 0.01), readmission (χ2 1 = 215.34, P < 0.01), revision surgery (χ2 1 = 171.21, P < 0.01) and removal of implants (χ2 1 = 4.31, P = 0.04) within 12 months of discharge. CONCLUSION These findings indicate that spine trauma SSIs are not associated with patient-reported outcomes and may not have lasting effects on patients. Larger studies are required to assess further follow-up and support our findings and possibly distinguish outcomes between superficial and deep SSI.
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Affiliation(s)
- Louay Baroun-Agob
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Susan Liew
- Monash Department of Surgery, The Alfred, Melbourne, Victoria, Australia.,Department of Orthopaedic Surgery, The Alfred, Melbourne, Victoria, Australia
| | - Belinda Gabbe
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Health Data Research UK, Swansea University Medical School, Swansea University, Swansea, UK
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11
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Zhou JJ, Hemphill C, Walker CT, Farber SH, Uribe JS. Adverse Effects of Perioperative Blood Transfusion in Spine Surgery. World Neurosurg 2021; 149:73-79. [PMID: 33540100 DOI: 10.1016/j.wneu.2021.01.093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Perioperative blood transfusion is often necessary during spine surgery because of blood loss from the surgical field during and after surgery. However, blood transfusions are associated with a small but significant risk of causing several adverse events including hemolytic transfusion reactions and transfusion-associated circulatory overload. Moreover, many prior publications have noted increased rates of perioperative morbidity and worsened outcomes in spine surgery patients who received blood transfusions. We performed a systematic review of the literature to better characterize the effects of blood transfusion on spine surgery outcomes. METHODS The PubMed/MEDLINE database was queried using the composite key word "transfus∗ AND 'spine surgery.'" A title and abstract review were performed to identify articles for final inclusion. RESULTS A title and abstract review of the resulting 372 English-language articles yielded 13 relevant publications, which were subsequently incorporated into this systematic review. All included studies were retrospective, nonrandomized analyses. CONCLUSIONS Overall, prior literature indicates a relationship between perioperative blood transfusion and worsened outcomes after spine surgery. However, the available data represent level IV evidence at best. In the future, prospective, randomized, controlled studies may help define the effects of perioperative blood transfusion on spine surgery outcomes.
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Affiliation(s)
- James J Zhou
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Courtney Hemphill
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Corey T Walker
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - S Harrison Farber
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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12
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Omar IH, Okasha AS, Ahmed AM, Saleh RS. Goal Directed Fluid Therapy based on Stroke Volume Variation and Oxygen Delivery Index using Electrical Cardiometry in patients undergoing Scoliosis Surgery. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1927418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Islam Hassan Omar
- Anesthesia and Surgical Intensive Care, Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ahmed Saied Okasha
- Anesthesia and Surgical Intensive Care, Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ahmed Mansour Ahmed
- Anesthesia and Surgical Intensive Care, Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Rabab Saber Saleh
- Anesthesia and Surgical Intensive Care, Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt
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13
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Pennington Z, Ehresman J, Westbroek EM, Lubelski D, Cottrill E, Sciubba DM. Interventions to minimize blood loss and transfusion risk in spine surgery: A narrative review. Clin Neurol Neurosurg 2020; 196:106004. [DOI: 10.1016/j.clineuro.2020.106004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/04/2020] [Accepted: 06/06/2020] [Indexed: 12/26/2022]
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The incidence and risk factors for perioperative allogeneic blood transfusion in primary idiopathic scoliosis surgery. Spine Deform 2020; 8:695-702. [PMID: 32152964 DOI: 10.1007/s43390-020-00093-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 02/14/2020] [Indexed: 10/24/2022]
Abstract
STUDY DESIGN Case-control study. OBJECTIVES Evaluate the rate and risk factors for perioperative allogeneic blood transfusion (ABT) in primary idiopathic scoliosis surgery at a single institution. Avoiding perioperative ABT is ideal as transfusions are associated with adverse reactions, increased rates of infection, prolonged hospitalization, additional laboratory testing, and increased cost. Risk factors identified in other studies have differed, and to our knowledge, few studies have identified clinical strategies to predict patients at high risk for ABT. METHODS We reviewed 402 idiopathic scoliosis patients who underwent primary posterior spinal fusion and instrumentation (PSFI) at a single institution from 2015 to 2017. Medical records and radiographs were reviewed for all patients. Transfused patients were compared to the remaining cohort to find significant differences and identify predictors of higher ABT risk. RESULTS ABT occurred in 73 patients (18.2%), with the majority of transfusions occurring intraoperatively (41%) or postoperatively on the day of surgery (25%). The seven surgeons involved varied significantly in incidence of ABT (2.4-35.8%, p = 0.002). Patients who had ABT were younger (13.3 vs. 14.1 years, p < 0.01), had lower BMI (48th vs. 61st percentile, p < 0.001), and lower preoperative hemoglobin (13.1 vs. 13.7 g/dL, p < 0.01). Greater preoperative major Cobb angle (69° vs. 61.5°, p < 0.001), number of fusion levels (11.8 vs. 10.3, p < 0.001), and estimated blood loss (770 vs. 448 mL, p < 0.001) also predicted ABT. CONCLUSIONS ABT was associated with several risk factors, five of which are known preoperatively. Surgeons can use knowledge of these risk factors to assess transfusion risk preoperatively and plan surgery, blood management, and laboratory testing accordingly. The development of best practices for ordering ABT is possible given the variation amongst providers. LEVEL OF EVIDENCE Level III.
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15
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Blood Management and Risk Assessment for Transfusion in Pediatric Spinal Deformity Surgery. Adv Hematol 2020; 2020:8246309. [PMID: 32454830 PMCID: PMC7229536 DOI: 10.1155/2020/8246309] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 04/06/2020] [Indexed: 11/29/2022] Open
Abstract
Objectives Evaluate the impact of a Quality and Safety Program (QSP) on the reduction of blood loss and transfusion needs in pediatric spinal deformity surgery, while defining risk factors for transfusion. Background Multimodal plan aiming to minimize transfusion needs has been shown to reduce transfusions and index rates in spinal deformity surgery. Anticipating blood loss and transfusion may help direct resources to patient needs or encourage reconsideration of the surgical plan. Methods This is a single-center retrospective study of prospectively collected data. Impact of this multimodal plan was studied on idiopathic deformities (Group A, 109 patients) and scoliosis associated with syndromic, neuromuscular, and muscular dystrophies (Group B, 100 patients), both before and after QSP. Results A decrease in total estimated blood loss was observed. In Group A, transfused patients decreased from 83.7% to 28% (p < 0.001, odds: 0.077), and, in Group B, from 98.7% to 66% (p < 0.01, odds: 0.038). Pearson's correlation identified patient body weight (r = 0.245, p=0.001) and Cobb angle (r = 0.175, p=0.017) as factors related to blood loss. A linear regression model to estimate hematic losses revealed that only body weight and transfusion showed predictive power, resulting in a low predictive model (R2 = 0.156; F(3,167) = 15.483, p < 0.001). A mediated model to explain blood loss was built based on a set of variables influencing transfusion which is, in turn, related to blood loss. Conclusion Transfusion needs in scoliosis surgery can be substantially reduced following a multimodal approach. The success of a program is strongly dependent on team effort, and the introduction of a risk assessment tool for transfusion needs indirectly assesses surgical risk, thus allowing relocation of resources to decrease blood loss.
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Buell TJ, Taylor DG, Chen CJ, Dunn LK, Mullin JP, Mazur MD, Yen CP, Shaffrey ME, Shaffrey CI, Smith JS, Naik BI. Rotational thromboelastometry-guided transfusion during lumbar pedicle subtraction osteotomy for adult spinal deformity: preliminary findings from a matched cohort study. Neurosurg Focus 2020; 46:E17. [PMID: 30933918 DOI: 10.3171/2019.1.focus18572] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 01/24/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVESignificant blood loss and coagulopathy are often encountered during adult spinal deformity (ASD) surgery, and the optimal intraoperative transfusion algorithm is debatable. Rotational thromboelastometry (ROTEM), a functional viscoelastometric method for real-time hemostasis testing, may allow early identification of coagulopathy and improve transfusion practices. The objective of this study was to investigate the effect of ROTEM-guided blood product management on perioperative blood loss and transfusion requirements in ASD patients undergoing correction with pedicle subtraction osteotomy (PSO).METHODSThe authors retrospectively reviewed patients with ASD who underwent single-level lumbar PSO at the University of Virginia Health System. All patients who received ROTEM-guided blood product transfusion between 2015 and 2017 were matched in a 1:1 ratio to a historical cohort treated using conventional laboratory testing (control group). Co-primary outcomes were intraoperative estimated blood loss (EBL) and total blood product transfusion volume. Secondary outcomes were perioperative transfusion requirements and postoperative subfascial drain output.RESULTSThe matched groups (ROTEM and control) comprised 17 patients each. Comparison of matched group baseline characteristics demonstrated differences in female sex and total intraoperative dose of intravenous tranexamic acid (TXA). Although EBL was comparable between ROTEM versus control (3200.00 ± 2106.24 ml vs 3874.12 ± 2224.22 ml, p = 0.36), there was a small to medium effect size (Cohen's d = 0.31) on EBL reduction with ROTEM. The ROTEM group had less total blood product transfusion volume (1624.18 ± 1774.79 ml vs 2810.88 ± 1847.46 ml, p = 0.02), and the effect size was medium to large (Cohen's d = 0.66). This difference was no longer significant after adjusting for TXA (β = -0.18, 95% confidence interval [CI] -1995.78 to 671.64, p = 0.32). More cryoprecipitate and less fresh frozen plasma (FFP) were transfused in the ROTEM group patients (cryoprecipitate units: 1.24 ± 1.20 vs 0.53 ± 1.01, p = 0.03; FFP volume: 119.76 ± 230.82 ml vs 673.06 ± 627.08 ml, p < 0.01), and this remained significant after adjusting for TXA (cryoprecipitate units: β = 0.39, 95% CI 0.05 to 1.73, p = 0.04; FFP volume: β = -0.41, 95% CI -772.55 to -76.30, p = 0.02). Drain output was lower in the ROTEM group and remained significant after adjusting for TXA.CONCLUSIONSFor ASD patients treated using lumbar PSO, more cryoprecipitate and less FFP were transfused in the ROTEM group compared to the control group. These preliminary findings suggest ROTEM-guided therapy may allow early identification of hypofibrinogenemia, and aggressive management of this may reduce blood loss and total blood product transfusion volume. Additional prospective studies of larger cohorts are warranted to identify the appropriate subset of ASD patients who may benefit from intraoperative ROTEM analysis.
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Affiliation(s)
| | | | | | - Lauren K Dunn
- 2Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Jeffrey P Mullin
- 3Department of Neurosurgery, University of Buffalo, New York; and
| | - Marcus D Mazur
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | | | | | | | | | - Bhiken I Naik
- Departments of1Neurosurgery and.,2Anesthesiology, University of Virginia, Charlottesville, Virginia
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Rates, Risk Factors, and Complications of Red Blood Cell Transfusion in Metastatic Spinal Tumor Surgery: An Analysis of a Prospective Multicenter Surgical Database. World Neurosurg 2020; 139:e308-e315. [PMID: 32298819 DOI: 10.1016/j.wneu.2020.03.202] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/27/2020] [Accepted: 03/29/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To identify rates, risks, and complications of red blood cell (RBC) transfusion in metastatic spinal tumor surgery. METHODS The multicenter prospective American College of Surgeons National Quality Improvement Program database was queried for the years 2012-2016. Adult patients with disseminated cancer who underwent metastatic spinal tumor surgery were identified. Transfusion was defined as having received at least 1 intraoperative/postoperative RBC transfusion within the first 72 hours of surgery start time. A stepwise multiple logistic regression model with backward elimination was used. RESULTS Of 1601 patients identified, 623 patients (38.9%) received a RBC transfusion. Independent predictors of RBC transfusion included higher American Society of Anesthesiologists class (odds ratio [OR] = 1.54), preoperative anemia (OR = 3.10), instrumentation (OR = 1.63), and longer operative time (OR = 1.52). The overall complication rate was significantly higher in patients who received a transfusion compared with patients who did not receive a transfusion (22.3% vs. 15.0%, P < 0.001). Individual complications that were more common in patients who received a transfusion were sepsis (3.5% vs. 1.9%, P = 0.050), deep vein thrombosis (6.1% vs. 3.3%, P = 0.007), and prolonged ventilation (3.9% vs. 1.3%, P = 0.001). RBC transfusion (OR = 1.65), hypoalbuminemia (OR = 1.53), and anterior/anterolateral approaches for corpectomy (OR = 2.11) were independent risk factors for developing a postoperative complication. CONCLUSIONS RBC transfusion after metastatic spinal tumor surgery may increase the risk of early postoperative complications. Future research into preoperative patient optimization and decreasing intraoperative blood loss is needed.
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Rembold SM, Santana RF, Oliveira Lopes MV, Melo UG. Nursing Diagnosis Risk for Delayed Surgical Recovery (00246) in Adult and Elderly: A Case‐Control Study. Int J Nurs Knowl 2020; 31:268-274. [DOI: 10.1111/2047-3095.12274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Mikhail C, Pennington Z, Arnold PM, Brodke DS, Chapman JR, Chutkan N, Daubs MD, DeVine JG, Fehlings MG, Gelb DE, Ghobrial GM, Harrop JS, Hoelscher C, Jiang F, Knightly JJ, Kwon BK, Mroz TE, Nassr A, Riew KD, Sekhon LH, Smith JS, Traynelis VC, Wang JC, Weber MH, Wilson JR, Witiw CD, Sciubba DM, Cho SK. Minimizing Blood Loss in Spine Surgery. Global Spine J 2020; 10:71S-83S. [PMID: 31934525 PMCID: PMC6947684 DOI: 10.1177/2192568219868475] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
STUDY DESIGN Broad narrative review. OBJECTIVE To review and summarize the current literature on guidelines, outcomes, techniques and indications surrounding multiple modalities of minimizing blood loss in spine surgery. METHODS A thorough review of peer-reviewed literature was performed on the guidelines, outcomes, techniques, and indications for multiple modalities of minimizing blood loss in spine surgery. RESULTS There is a large body of literature that provides a consensus on guidelines regarding the appropriate timing of discontinuation of anticoagulation, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements prior to surgery. Additionally, there is a more heterogenous discussion the utility of preoperative autologous blood donation facilitated by erythropoietin and iron supplementation for healthy patients slated for procedures with high anticipated blood loss and for whom allogeneic transfusion is likely. Intraoperative maneuvers available to minimize blood loss include positioning and maintaining normothermia. Tranexamic acid (TXA), bipolar sealer electrocautery, and topical hemostatic agents, and hypotensive anesthesia (mean arterial pressure (MAP) <65 mm Hg) should be strongly considered in cases with larger exposures and higher anticipated blood loss. There is strong level 1 evidence for the use of TXA in spine surgery as it reduces the overall blood loss and transfusion requirements. CONCLUSION As the volume and complexity of spinal procedures rise, intraoperative blood loss management has become a pivotal topic of research within the field. There are many tools for minimizing blood loss in patients undergoing spine surgery. The current literature supports combining techniques to use a cost- effective multimodal approach to minimize blood loss in the perioperative period.
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Affiliation(s)
| | | | - Paul M. Arnold
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Norman Chutkan
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - John G. DeVine
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Daniel E. Gelb
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Fan Jiang
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Brian K. Kwon
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas E. Mroz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ahmad Nassr
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - K. Daniel Riew
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lali H. Sekhon
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | | | | | | | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Samuel K. Cho, Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY 10029, USA.
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Mantoani CC, Margatho AS, Dantas RAS, Galvão CM, de Campos Pereira Silveira RC. Perioperative Blood Transfusion and Occurrence of Surgical Site Infection: An Integrative Review. AORN J 2019; 110:626-634. [PMID: 31774169 DOI: 10.1002/aorn.12861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The aim of this integrative review was to locate, assess, and synthesize available evidence of the relationship between perioperative allogeneic blood transfusion and the occurrence of surgical site infection among adult patients undergoing elective surgery. After a comprehensive search of relevant databases and a review of the studies this yielded, we used a validated instrument to extract data from the 25 studies in our final sample. The clinical and surgical variables that were significantly and more frequently associated with the occurrence of surgical site infection among patients who received blood transfusions during the perioperative period were female sex, older age, and higher body mass index. Our findings indicate a lack of consensus on the hemoglobin levels that indicate a blood transfusion is necessary.
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21
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Burton DC, Sethi RK, Wright AK, Daniels AH, Ames CP, Reid DB, Klineberg EO, Harper R, Mundis GM, Hlubek RJ, Bess S, Hart RA, Kelly MP, Lenke LG. The Role of Potentially Modifiable Factors in a Standard Work Protocol to Decrease Complications in Adult Spinal Deformity Surgery: A Systematic Review, Part 1. Spine Deform 2019; 7:669-683. [PMID: 31495466 DOI: 10.1016/j.jspd.2019.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 04/01/2019] [Accepted: 04/12/2019] [Indexed: 11/30/2022]
Abstract
STUDY DESIGN Structured Literature Review. OBJECTIVES We sought to evaluate the peer-reviewed literature for potentially modifiable patient and surgical factors that could be incorporated into a Standard Work protocol to decrease complications in adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA Lean Methodology uses Standard Work to improve efficiency and decrease waste and error. ASD is known to have a high surgical complication rate. Several patient and surgical potentially modifiable factors have been suggested to affect complications, including preoperative hemoglobin, bone density, body mass index (BMI), age-appropriate realignment, preoperative albumin/prealbumin, and smoking status. We sought to evaluate the literature for evidence supporting these factors to include in a Standard Work protocol to decrease complications. METHODS Each of these six factors was developed into an appropriate clinical question that included the patient population, surgical intervention, a comparison group, and outcomes measure (PICO question). A comprehensive literature search was then performed. The authors reviewed abstracts and analyzed data from included studies. From 456 initial citations with abstract, 173 articles underwent full-text review. The best available evidence for clinical questions regarding the influence of these factors was provided by 93 included studies. RESULTS We found fair evidence supporting a low preoperative hemoglobin level associated with increased transfusion rates and decreased BMD and increased BMI associated with increased complication rates. Fair evidence supported low albumin/prealbumin associated with increased complications. There was fair evidence associating smoking exposure to increased reoperations, but conflicting evidence associating it with increased complications. There was no evidence in the literature evaluating age-appropriate realignment and complications. CONCLUSION Preoperative hemoglobin, bone density, body mass index, preoperative albumin/prealbumin, and smoking status all are potentially modifiable risk factors that are associated with increased complications in the adult spine surgery population. Developing a Standard Work Protocol for patient evaluation and optimization should include these factors. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA.
| | - Rajiv K Sethi
- Neuroscience Institute, Virginia Mason Hospital, 1100 Ninth Avenue, Seattle, WA 98101, USA; Department of Health Services, University of Washington, NE Pacific Street, Seattle, WA 98195, USA
| | - Anna K Wright
- Neuroscience Institute, Virginia Mason Hospital, 1100 Ninth Avenue, Seattle, WA 98101, USA
| | - Alan H Daniels
- Department of Orthopedics, Brown University, 222 Richmond Street, Providence, RI 02912, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California San Francisco, 513 Parnassus Avenue, San Francisco, CA 94131, USA
| | - Daniel B Reid
- Department of Orthopedics, Brown University, 222 Richmond Street, Providence, RI 02912, USA
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California, 1 Shields Avenue, Davis, CA 95616, USA
| | - Robert Harper
- Department of Orthopedic Surgery, University of California, 1 Shields Avenue, Davis, CA 95616, USA
| | - Gregory M Mundis
- San Diego Spine Foundation, 6190 Cornerstone Ct. E, Suite 212, San Diego, CA 92121, USA
| | - Randall J Hlubek
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's Medical Center, Rocky Mountain Hospital for Children, 2055 High Street, Suite 130, Denver, CO 80205, USA
| | - Robert A Hart
- Swedish Neuroscience Institute, 550 17th Avenue, Suite 540, Seattle, WA 98122, USA
| | - Michael P Kelly
- Department of Orthopaedics, Washington University St. Louis, 1 Brookings Dr., St. Louis, MO 63130, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University, Och Spine Hospital, 5141 Broadway, New York, NY 10034, USA
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He YK, Li HZ, Lu HD. Is blood transfusion associated with an increased risk of infection among spine surgery patients?: A meta-analysis. Medicine (Baltimore) 2019; 98:e16287. [PMID: 31305412 PMCID: PMC6641843 DOI: 10.1097/md.0000000000016287] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 05/01/2019] [Accepted: 06/07/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Blood transfusions are associated with many adverse outcomes among spine surgery patients, but it remains unclear whether perioperative blood transfusion during spine surgery and postoperative infection are related. Recently, many related cohort studies have been published on this topic. METHODS This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The PubMed, Embase, and Cochrane Library databases were searched for eligible published studies. The Newcastle-Ottawa Scale (NOS) was used to assess the methodological quality of the studies, and a random-effects model was used to calculate the odds ratios (ORs) with 95% CIs. Sensitivity analyses were conducted to explore the source of heterogeneity. RESULTS The final analysis included 8 cohort studies with a total of 34,185 spine surgery patients. These studies were considered to be of high or moderate quality based on their NOS scores, which ranged from 5 to 9. Pooled estimates indicated that blood transfusion increased the infection rate (OR, 2.99; 95% CI, 1.95 to 4.59; I = 86%), which was consistent with the sensitivity analyses. CONCLUSIONS Our results suggest that perioperative blood transfusion is a risk factor for postoperative infection among spine surgery patients. Further study is necessary to identify other influencing factors and to establish the mechanism underlying this relationship. Additional measures may be needed to reduce unnecessary blood transfusions during spine surgery.
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Alfonso AR, Hutzler L, Lajam C, Bosco J, Goldstein J. Institution-Wide Blood Management Protocol Reduces Transfusion Rates Following Spine Surgery. Int J Spine Surg 2019; 13:270-274. [PMID: 31328091 DOI: 10.14444/6036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Background Spine surgery is associated with significant intraoperative blood loss, often leading to transfusion. Patients who receive transfusions have an increased length of stay and risk of perioperative complications. To decrease the transfusion rate, we implemented an evidence-based institution-wide restrictive transfusion blood management guideline. The goal of this study is to describe the impact of this guideline on our spine surgery patients. Methods We analyzed the incidence of transfusion following 3709 single-institution, inpatient spine procedures before and after implementation of a revised blood transfusion protocol. The baseline period (1742 patients) from January 2014 to March 2015 was compared to the study period (1967 patients) of April 2015 to July 2016. One patient was excluded because of incomplete medical records. The revised protocol included establishing a postoperative blood transfusion trigger at hemoglobin < 7g/dL, instituting a computerized provider order entry, and appointing a physician champion to monitor and report progress. Results Transfusion rate decreased from 16.2% to 9.7% from baseline to study period, respectively (P < .001). The number of transfusions in patients with hemoglobin > 7g/dL decreased to 4.9% from 6.1% (P = .09). The rate of transfusions with a prior hemoglobin test increased from 42.0% to 59.1% (P < .001). Length of stay was reduced from 3.67 to 3.46 days (P = .04), and postsurgical infection rate was reduced from 1.5% to 0.6% (P = .01). There was no significant difference in total hospital costs following protocol implementation. Conclusions Implementation of a restrictive transfusion protocol through use of a computerized provider order entry and a physician champion to oversee clinician compliance led to a 40.1% reduction in blood transfusion following spine surgery. Behavior changes were visible with a 40.7% increase in hemoglobin documentation before transfusion, and patients benefited from a reduction in length of stay and postsurgical infection rate. Future study is encouraged to understand the long-term impact of this intervention and its role in hospital expenditure.
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Affiliation(s)
| | | | | | - Joseph Bosco
- NYU Langone Orthopedic Hospital, New York, New York
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Blackburn CW, Morrow KL, Tanenbaum JE, DeCaro JE, Gron JM, Steinmetz MP. Clinical Outcomes Associated With Allogeneic Red Blood Cell Transfusions in Spinal Surgery: A Systematic Review. Global Spine J 2019; 9:434-445. [PMID: 31218203 PMCID: PMC6562214 DOI: 10.1177/2192568218769604] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES The objectives of this systematic review were to report the available clinical evidence on patient outcomes associated with perioperative allogeneic red blood cell (RBC) transfusions in adult patients undergoing spinal surgery and to determine whether there is any evidence to support an association between transfusion timing and clinical outcomes. METHODS A systematic review of the PubMed, EMBASE, and Cochrane Library databases was performed to identify all articles examining outcomes of adult spinal surgery patients who received perioperative allogeneic RBC transfusions. The level of evidence for each study was assessed using the "Oxford Levels of Evidence 2" classification system. Meta-analysis was not performed due to the heterogeneity of reports. RESULTS A total of 2759 unique citations were identified and 76 studies underwent full-text review. Thirty-four studies were selected for analysis. All the studies, except one, were retrospective. Eleven studies investigated intraoperative or postoperative transfusions. Only one article compared outcomes related to intraoperative versus postoperative transfusions. CONCLUSIONS Perioperative transfusion is associated with increased rates of postoperative complications, especially infectious complications, and prolonged length of stay. Some evidence suggests that a dose-response relationship may exist between morbid events and the number of RBC units administered, but these findings are inconsistent. Because of the heterogeneity of reports and inconsistent findings, the incidence of specific complications remains unclear. Limited research activity has focused on intraoperative versus postoperative transfusions, or the effect of transfusion on functional outcomes of spine surgery patients. Further research is warranted to address these clinical issues.
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Affiliation(s)
- Collin W. Blackburn
- Cleveland Clinic, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Katherine L. Morrow
- Cleveland Clinic, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Joseph E. Tanenbaum
- Cleveland Clinic, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
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Risk Factors for Surgical Site Infection After Spinal Surgery: A Systematic Review and Meta-Analysis Based on Twenty-Seven Studies. World Neurosurg 2019; 123:e318-e329. [DOI: 10.1016/j.wneu.2018.11.158] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/16/2018] [Accepted: 11/18/2018] [Indexed: 11/18/2022]
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Lin JD, Lenke LG, Shillingford JN, Laratta JL, Tan LA, Fischer CR, Weller MA, Lehman RA. Safety of a High-Dose Tranexamic Acid Protocol in Complex Adult Spinal Deformity: Analysis of 100 Consecutive Cases. Spine Deform 2018; 6:189-194. [PMID: 29413743 DOI: 10.1016/j.jspd.2017.08.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 08/08/2017] [Indexed: 11/15/2022]
Abstract
STUDY DESIGN Retrospective review of high-dose tranexamic acid (TXA) use in consecutive patients. OBJECTIVE To determine the safety profile of a high-dose TXA protocol in complex adult spinal deformity patients. SUMMARY OF BACKGROUND DATA Adult spinal deformity (ASD) surgery may involve significant amounts of blood loss, especially when various osteotomy techniques are used. Antifibrinolytic agents such as TXA have been used to reduce intraoperative blood loss. However, there is no universally accepted dosing protocol for its use during complex ASD surgery. METHODS Consecutive patients undergoing spinal deformity correction over a 14-month period at a single institution were identified. Inclusion criteria were adults (age ≥18 years) who underwent posterior spinal fusion of at least 5 levels and use of our standard TXA protocol of 50 mg/kg intravenous loading dose followed by a 5-mg/kg/h infusion until skin closure. Patient demographics, estimated blood loss (EBL), operative time, transfusion rates, complications, and other procedure-specific information were recorded. RESULTS A total of 100 adult patients were included. All operative procedures were performed by the senior surgeon. The mean age was 47.3 years, and 71% of patients were female. Average body mass index was 24.9. The average fusion length was 14 levels; 33/100 patients had fusion constructs of 17 levels or more. Pedicle subtraction osteotomy was performed in 9 patients and vertebral column resections were performed in 14 patients. There were 45/100 patients who had a primary procedure, whereas the rest were revisions. Mean EBL was 1,336 mL (98 mL/level, 31% estimated blood volume). There were three thromboembolic complications, including one pulmonary embolism and two deep vein thromboses (DVTs), which were all treated successfully with anticoagulation. There were no cases of myocardial infarction, seizure, stroke, or acute renal failure. CONCLUSIONS This is the first study to demonstrate the use of high-dose TXA in a complex ASD population. Larger prospective studies are needed to assess the efficacy and safety of high-dose TXA in ASD. LEVEL OF EVIDENCE Level IV, therapeutic.
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Affiliation(s)
- James D Lin
- Division of Spine Surgery, Columbia University Department of Orthopedic Surgery, The Spine Hospital at New York Presbyterian/Allen, 5141 Broadway, New York, NY 10034, USA
| | - Lawrence G Lenke
- Division of Spine Surgery, Columbia University Department of Orthopedic Surgery, The Spine Hospital at New York Presbyterian/Allen, 5141 Broadway, New York, NY 10034, USA.
| | - Jamal N Shillingford
- Division of Spine Surgery, Columbia University Department of Orthopedic Surgery, The Spine Hospital at New York Presbyterian/Allen, 5141 Broadway, New York, NY 10034, USA
| | - Joseph L Laratta
- Division of Spine Surgery, Columbia University Department of Orthopedic Surgery, The Spine Hospital at New York Presbyterian/Allen, 5141 Broadway, New York, NY 10034, USA
| | - Lee A Tan
- Division of Spine Surgery, Columbia University Department of Orthopedic Surgery, The Spine Hospital at New York Presbyterian/Allen, 5141 Broadway, New York, NY 10034, USA
| | - Charla R Fischer
- Division of Spine Surgery, Columbia University Department of Orthopedic Surgery, The Spine Hospital at New York Presbyterian/Allen, 5141 Broadway, New York, NY 10034, USA
| | - Mark A Weller
- Division of Spine Surgery, Columbia University Department of Orthopedic Surgery, The Spine Hospital at New York Presbyterian/Allen, 5141 Broadway, New York, NY 10034, USA
| | - Ronald A Lehman
- Division of Spine Surgery, Columbia University Department of Orthopedic Surgery, The Spine Hospital at New York Presbyterian/Allen, 5141 Broadway, New York, NY 10034, USA
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Abstract
STUDY DESIGN Retrospective literature review of spine surgical site infection (SSI). OBJECTIVE To perform a review of SSI risk factors and more specifically, categorize them into patient and surgical factors. METHODS A review of published literature on SSI risk factors in adult spine surgery was performed. We included studies that reported risk factors for SSI in adult spinal surgery. Excluded are pediatric patient populations, systematic reviews, and meta-analyses. Overall, we identified 72 cohort studies, 1 controlled-cohort study, 1 matched-cohort study, 1 matched-paired cohort study, 12 case-controlled studies (CCS), 6 case series, and 1 cross-sectional study. RESULTS Patient-associated risk factors-diabetes mellitus, obesity (body mass index >35 kg/m2), subcutaneous fat thickness, multiple medical comorbidities, current smoker, and malnutrition were associated with SSI. Surgical associated factors-preoperative radiation/postoperative blood transfusion, combined anterior/posterior approach, surgical invasiveness, or levels of instrumentation were associated with increased SSI. There is mixed evidence of age, duration of surgery, surgical team, intraoperative blood loss, dural tear, and urinary tract infection/urinary catheter in association with SSI. CONCLUSION SSIs are associated with many risk factors that can be patient or surgically related. Our review was able to identify important modifiable and nonmodifiable risk factors that can be essential in surgical planning and discussion with patients.
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Affiliation(s)
- Reina Yao
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Hanbing Zhou
- University of British Columbia, Vancouver, British Columbia, Canada,Hanbing Zhou, Division of Spine Surgery, Department of Orthopaedics, University of British Columbia, 3114–910 West 10th Avenue, Vancouver, British Columbia, V5Z 1M9, Canada.
| | | | - Brian K. Kwon
- University of British Columbia, Vancouver, British Columbia, Canada
| | - John Street
- University of British Columbia, Vancouver, British Columbia, Canada
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Chen YC, Zhang L, Li EN, Ding LX, Zhang GA, Hou Y, Yuan W. One or Two Drains for the Treatment of Surgical Site Infections After Lumbar Spine Surgery. World Neurosurg 2018; 116:e18-e25. [DOI: 10.1016/j.wneu.2018.02.142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 02/21/2018] [Accepted: 02/23/2018] [Indexed: 12/09/2022]
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Meng Y, Wang X, Chen H, Hong Y, Wu T, Wang B, Deng Y, Liu H. Risk Factors for Significant Intraoperative Blood Loss During Unilateral Expansive Open-Door Cervical Laminoplasty for Cervical Compressive Myelopathy. World Neurosurg 2018; 114:e1253-e1260. [PMID: 29625309 DOI: 10.1016/j.wneu.2018.03.186] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 03/24/2018] [Accepted: 03/26/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Unilateral expansive open-door cervical laminoplasty is an effective and safe procedure for cervical compressive myelopathy but occasionally is accompanied with significant intraoperative blood loss (SIBL). The aim of the present study was to elucidate the risk factors for SIBL in patients undergoing cervical laminoplasty for multilevel cervical compressive myelopathy and to identify the effect of SIBL on neurologic complications. METHODS A total of 215 patients who received cervical laminoplasty between January 2010 and August 2016 were enrolled in the study. SIBL was defined as 500 mL or more of blood volume during surgery. Patients were subdivided into 2 groups according to whether they suffered from SIBL (n = 26) or not (n = 189). Patient characteristics and clinical data were collected. Univariate and multivariable analysis were performed to identify independent risk factors for SIBL. RESULTS The incidence of SIBL during unilateral expansive open-door cervical laminoplasty was 12.1%. The multivariable logistic regression analysis showed Pavlov ratio (odds ratio [OR] 0.002, P = 0.009), ossification of the posterior longitudinal ligament (OR 2.677, P = 0.038), and number of complete hinge fractures (OR 1.842, P = 0.015) were independent risk factors for SIBL during cervical laminoplasty. Patients with SIBL during cervical laminoplasty had a greater rate of neurologic complications during hospitalization (P = 0.012), worse neurologic recovery rate at discharge (P = 0.01), and longer postoperative length of stay (P = 0.003). CONCLUSIONS This study suggested that Pavlov ratio, ossification of the posterior longitudinal ligament, and number of complete hinge fractures were independent risk factors for SBIL during cervical laminoplasty. SIBL in cervical laminoplasty was associated with greater neurologic complications and worse neurologic functional recovery.
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Affiliation(s)
- Yang Meng
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Sichuan, China
| | - Xiaofei Wang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Sichuan, China
| | - Hua Chen
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Sichuan, China
| | - Ying Hong
- Department of Operation Room, West China Hospital, Sichuan University, Sichuan, China
| | - Tingkui Wu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Sichuan, China
| | - Beiyu Wang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Sichuan, China
| | - Yuxiao Deng
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Sichuan, China
| | - Hao Liu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Sichuan, China.
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[Prevention of postoperative infections : Risk factors and the current WHO guidelines in musculoskeletal surgery]. Unfallchirurg 2018; 120:472-485. [PMID: 28573554 DOI: 10.1007/s00113-017-0362-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Despite the many scientific and technological advances postoperative infection continues to be a large problem for trauma and orthopedic surgeons. Based on a review of the current literature, this study provides a comprehensive overview of the risk factors (RF) and possible preventive measures to control surgical site infections. METHODS Medline search and analysis from 1968-2017 (as of 01 March 2017). Selection of trauma and orthopedic relevant RFs and comparison with WHO recommendations (global guidelines for the prevention of surgical site infection, Nov. 2016). RESULTS Identification of 858 relevant articles from the last 50 years (1968-2017). Pooled postoperative rate of infection is 0.3% (hand surgery) and 19% (3rd degree open fractures). For open fractures, there is no clear tendency towards lower infection rates during the past five decades. Identification of 115 RF from three areas (patient-dependent RF, organizational and procedural RF, trauma- and surgery-dependent RF). The five most important RFs are body mass index over 35 kg/m2, increased duration of surgery, diabetes mellitus, increased blood glucose levels in the perioperative period also in the case of nondiabetic patients, and errors in the perioperative antibiotic prophylaxis. DISCUSSION Inconsistent definition of "infection", interaction of the RF and the different follow-up duration limit the meaningfulness of the study. CONCLUSION In the future, considerable efforts must be made in order to achieve a noticeable reduction in the rate of infection, especially in the case of high-risk patients.
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Coagulation Profile as a Risk Factor for 30-day Morbidity Following Cervical Laminectomy and Fusion. Spine (Phila Pa 1976) 2018; 43:239-247. [PMID: 28658042 DOI: 10.1097/brs.0000000000002301] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis of prospectively collected data. OBJECTIVE The aim of this study was to determine the ability of abnormal coagulation profile to predict adverse events following posterior cervical laminectomy and fusion (PCLF). SUMMARY OF BACKGROUND DATA PCLF is an increasingly common procedure used to treat a variety of traumatic and degenerative spinal conditions. Abnormal coagulation profile is associated with postoperative adverse events, including blood transfusion. There is a paucity of literature that specifically addresses the relationship between coagulation profile and complications following PCLF. METHODS ACS-NSQIP was utilized to identify patients undergoing PCLF between 2006 and 2013. A total of 3546 patients met inclusion criteria. Multivariate analysis was utilized to identify associations between abnormal coagulation profile and postoperative complications. RESULTS Membership in the low-platelet cohort was an independent risk factor for myocardial infarction (Odds Ratio (OR) = 5.4 [1.0, 29.1], P = 0.049) and bleeding transfusion (OR = 2.0 [1.2, 3.4], P = 0.011). Membership in the high international normalized ratio group was an independent risk factor for pneumonia (OR = 6.3 [2.5, 16.1], P < 0.001), ventilation >48 hours (OR = 6.5 [2.3, 18.4], P < 0.001), organ space surgical site infection (OR = 11.1 [2.1, 57.3], P = 0.004), urinary tract infection (OR = 3.0 [1.2, 8.0], P = 0.024), bleeding transfusion (OR = 6.0 [3.4, 10.7], P < 0.001), sepsis (OR = 5.1 [1.6, 16.4], P = 0.006), and septic shock (OR = 6.8 [1.7, 27.4], P = 0.007). Membership in the bleeding disorders cohort was an independent predictor of unplanned intubation (OR = 3.2 [1.1, 9.5], P = 0.041), pneumonia (OR = 2.9 [1.2, 7.2], P = 0.023), ventilation >48 hours (OR = 4.8 [1.9, 12.4], P = 0.001), cerebrovascular accident/stroke with neurological deficit (OR = 24.8 [2.9, 210.6], P = 0.003), bleeding transfusion (OR = 2.1 [1.1, 4.1], P = 0.032), reoperation (OR = 3.6 [1.4, 9.3], P = 0.008), and sepsis (OR = 3.4 [1.1, 10.4], P = 0.031). CONCLUSION This is the first large study to document abnormal coagulation profile as an independent predictor of outcomes following PCLF. Abnormal coagulation profile represents a predictor of complications that can be medically mitigated, and is therefore a valuable parameter to assess preoperatively. Coagulation profile should continue to play a role in targeting patients for risk stratification, preoperative optimization, and quality improvement initiatives. LEVEL OF EVIDENCE 3.
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Zaw AS, Kantharajanna SB, Maharajan K, Tan B, Saparamadu AA, Kumar N. Metastatic spine tumor surgery: does perioperative blood transfusion influence postoperative complications? Transfusion 2017; 57:2790-2798. [DOI: 10.1111/trf.14311] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 06/17/2017] [Accepted: 06/20/2017] [Indexed: 01/28/2023]
Affiliation(s)
- Aye Sandar Zaw
- Department of Orthopaedic Surgery; National University Hospital; Singapore
| | | | | | - Barry Tan
- Department of Orthopaedic Surgery; National University Hospital; Singapore
| | | | - Naresh Kumar
- Department of Orthopaedic Surgery; National University Hospital; Singapore
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Jones KE, Butler EK, Barrack T, Ledonio CT, Forte ML, Cohn CS, Polly DW. Tranexamic Acid Reduced the Percent of Total Blood Volume Lost During Adolescent Idiopathic Scoliosis Surgery. Int J Spine Surg 2017; 11:27. [PMID: 29372131 DOI: 10.14444/4027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Multilevel posterior spine fusion is associated with significant intraoperative blood loss. Tranexamic acid is an antifibrinolytic agent that reduces intraoperative blood loss. The goal of this study was to compare the percent of total blood volume lost during posterior spinal fusion (PSF) with or without tranexamic acid in patients with adolescent idiopathic scoliosis (AIS). Methods Thirty-six AIS patients underwent PSF in 2011-2014; the last half (n=18) received intraoperative tranexamic acid. We retrieved relevant demographic, hematologic, intraoperative and outcomes information from medical records. The primary outcome was the percent of total blood volume lost, calculated from estimates of intraoperative blood loss (numerator) and estimated total blood volume per patient (denominator, via Nadler's equations). Unadjusted outcomes were compared using standard statistical tests. Results Tranexamic acid and no-tranexamic acid groups were similar (all p>0.05) in mean age (16.1 vs. 15.2 years), sex (89% vs. 83% female), body mass index (22.2 vs. 20.2 kg/m2), preoperative hemoglobin (13.9 vs. 13.9 g/dl), mean spinal levels fused (10.5 vs. 9.6), osteotomies (1.6 vs. 0.9) and operative duration (6.1 hours, both). The percent of total blood volume lost (TBVL) was significantly lower in the tranexamic acid-treated vs. no-tranexamic acid group (median 8.23% vs. 14.30%, p = 0.032); percent TBVL per level fused was significantly lower with tranexamic acid than without it (1.1% vs. 1.8%, p=0.048). Estimated blood loss (milliliters) was similar across groups. Conclusions Tranexamic acid significantly reduced the percentage of total blood volume lost versus no tranexamic acid in AIS patients who underwent PSF using a standardized blood loss measure.Level of Evidence: 3. Institutional Review Board status: This medical record chart review (minimal risk) study was approved by the University of Minnesota Institutional Review Board.
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Affiliation(s)
- Kristen E Jones
- Departments of Orthopaedic Surgery and Neurosurgery, University of Minnesota, Minneapolis, MN
| | - Elissa K Butler
- Department of Surgery, University of Washington, Seattle, WA
| | | | - Charles T Ledonio
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN
| | - Mary L Forte
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN
| | - Claudia S Cohn
- Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - David W Polly
- Departments of Orthopaedic Surgery and Neurosurgery, University of Minnesota, Minneapolis, MN
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Fluid Overload and Cumulative Thoracostomy Output Are Associated With Surgical Site Infection After Pediatric Cardiothoracic Surgery. Pediatr Crit Care Med 2017; 18:770-778. [PMID: 28486386 DOI: 10.1097/pcc.0000000000001193] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the impact of cumulative, postoperative thoracostomy output, amount of bolus IV fluids and peak fluid overload on the incidence and odds of developing a deep surgical site infection following pediatric cardiothoracic surgery. DESIGN A single-center, nested, retrospective, matched case-control study. SETTING A 26-bed cardiac ICU in a 303-bed tertiary care pediatric hospital. PATIENTS Cases with deep surgical site infection following cardiothoracic surgery were identified retrospectively from January 2010 through December 2013 and individually matched to controls at a ratio of 1:2 by age, gender, Risk Adjustment for Congenital Heart Surgery score, Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery category, primary cardiac diagnosis, and procedure. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Twelve cases with deep surgical site infection were identified and matched to 24 controls without detectable differences in perioperative clinical characteristics. Deep surgical site infection cases had larger thoracostomy output and bolus IV fluid volumes at 6, 24, and 48 hours postoperatively compared with controls. For every 1 mL/kg of thoracostomy output, the odds of developing a deep surgical site infection increase by 13%. By receiver operative characteristic curve analysis, a cutoff of 49 mL/kg of thoracostomy output at 48 hours best discriminates the development of deep surgical site infection (sensitivity 83%, specificity 83%). Peak fluid overload was greater in cases than matched controls (12.5% vs 6%; p < 0.01). On receiver operative characteristic curve analysis, a threshold value of 10% peak fluid overload was observed to identify deep surgical site infection (sensitivity 67%, specificity 79%). Conditional logistic regression of peak fluid overload greater than 10% on the development of deep surgical site infection yielded an odds ratio of 9.4 (95% CI, 2-46.2). CONCLUSIONS Increased postoperative peak fluid overload and cumulative thoracostomy output were associated with deep surgical site infection after pediatric cardiothoracic surgery. We suspect the observed increased thoracostomy output, fluid overload, and IV fluid boluses may have altered antimicrobial prophylaxis. Although analysis of additional pharmacokinetic data is warranted, providers may consider modification of antimicrobial prophylaxis dosing or alterations in fluid management and diuresis in response to assessment of peak fluid overload and fluid volume shifts in the immediate postoperative period.
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Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The objective of this study is to compare the incidence of infection in patients who do and do not receive blood transfusions in major deformity surgery (>8 levels). SUMMARY OF BACKGROUND DATA Postoperative infections increase morbidity and mortality rates in spine surgery and generate additional costs for the health care system. It has been proposed that blood transfusions increase the risk of wound infection, urinary tract infection, pneumonia, and sepsis. METHODS A total of 56 patients met the study criteria, receiving spine surgery involving the fusion of 8 levels or more. Patient-specific characteristics, starting and ending hematocrits, number of units transfused and infections including urinary tract infection, wound infection, pneumonia, and sepsis were documented. Differences in infection risk between those who did and did not undergo a transfusion and their 95% confidence intervals were calculated. RESULTS Groups were similar with respect to baseline and surgical characteristics except for smoking status, operative time, estimated blood loss, and ending hematocrit. The overall infection rate was greater in patients who underwent transfusion than those who did not (36% vs. 10%; P=0.03). Wound infections (n=5) were only observed in those who underwent a transfusion. Smokers were more likely to receive a transfusion and more likely to experience infection. A stratified analysis demonstrated an increased risk of infection associated with transfusion; however, the risk was greater in smokers, suggesting the effect of transfusion on infection could be modified by smoking. Patients undergoing transfusion experienced a significantly longer hospital stay (P=0.01). CONCLUSIONS Allogeneic red blood cell transfusion in major spine surgery could be a risk factor for postoperative infection. This increased risk seems to be magnified in those who smoke. Further studies are warranted, and risks of blood loss and transfusion-related complications in smokers also potentially merit exploration. LEVEL OF EVIDENCE Level 3.
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Thrombotic and Infectious Morbidity Are Associated with Transfusion in Posterior Spine Fusion. HSS J 2017; 13:152-158. [PMID: 28690465 PMCID: PMC5481266 DOI: 10.1007/s11420-017-9545-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 01/11/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although previous investigators have established an association between blood transfusion and adverse outcomes, the relative frequency of different morbid events and the association with transfusion dose are not well understood. QUESTIONS/PURPOSES The purpose of the study is to characterize the relationship between blood transfusion and different types of morbidity after posterior spine fusion. METHODS We retrospectively analyzed electronic medical records for 963 patients who underwent posterior spinal fusion surgery at a single institution, of which 603 (62.6%) received an allogeneic blood transfusion. Then, we assessed patient and surgical characteristics in a risk-adjusted fashion to identify various morbid event rates and independent predictors in these adverse outcomes. RESULTS Compared to the non-transfused patients, transfused patients had a higher incidence of any morbid event (9.1 vs. 2.5%. P < 0.0001), thrombotic events (4.6 vs. 1.1%, P = 0.0025), and hospital-acquired infections (2.3 vs. 0.6%, P = 0.039). Renal, respiratory, and ischemic morbidity occurred less frequently and were not more common in transfused patients. Risk-adjusted analysis revealed a dose-response effect, whereby for each unit of allogeneic blood transfused, the risks of any morbid event (OR 1.183; 95% CI 1.103-1.274; P < 0.0001), thrombotic complication (OR 1.104; 95% CI 1.032-1.194; P = 0.0035), and infectious complication (OR 1.182; 95% CI 1.077-1.332; P = 0.0002) were increased. CONCLUSION Our data demonstrate risk-adjusted and transfusion dose-related increases in perioperative morbidity, with thrombotic and infectious events being the most common.
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Coagulation Profile as a Risk Factor for 30-Day Morbidity and Mortality Following Posterior Lumbar Fusion. Spine (Phila Pa 1976) 2017; 42:950-957. [PMID: 27755500 DOI: 10.1097/brs.0000000000001935] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE The aim of this study was to identify associations between abnormal coagulation profile and postoperative morbidity and mortality in patients undergoing posterior lumbar fusion (PLF). SUMMARY OF BACKGROUND DATA The literature suggests that abnormal coagulation profile is associated with postoperative complications, notably the need for blood transfusion. However, there is little research that directly addresses the influence of coagulation profile on postoperative complications following PLF. METHODS The American College of Surgeons National Surgical Quality Improvement Program database (ACS-NSQIP) was utilized to identify patients undergoing PLF between 2006 and 2013. Nine thousand two hundred ninety-five patients met inclusion criteria. Multivariate analysis was utilized to identify associations between abnormal coagulation profile and postoperative complications. RESULTS Low platelet count was an independent risk factor for organ space surgical site infections (SSIs) [odds ratio (OR) = 6.0, P < 0.001], ventilation >48 hours (OR = 4.5, P = 0.002), Acute renal failure (OR = 5.8, P = 0.007), transfusion (OR = 1.6, P < 0.001), sepsis (OR = 2.2, P = 0.037), reoperation (OR = 2.5, P = 0.001), and death (OR = 3.7, P = 0.049). High partial thromboplastin time (PTT) was an independent risk factor for ventilation >48 hours (OR = 5.6, P = 0.002), cerebrovascular accident (CVA)/stroke with neurological deficit (OR = 5.1, P = 0.011), cardiac arrest (OR = 5.4, P = 0.030), transfusion (OR = 1.5, P = 0.020), and death (OR = 4.5, P = 0.050). High International Normalized Ration (INR) was an independent risk factor for pneumonia (OR = 8.7, P = 0.001), pulmonary embolism (OR = 5.6, P = 0.021), deep venous thrombosis/Thrombophlebitis (OR = 4.8, P = 0.011), septic shock (OR = 8.4, P = 0.048), and death (OR = 9.8, P = 0.034). Bleeding disorder was an independent risk factor for organ space SSI (OR = 5.4, P = 0.01), pneumonia (OR = 3.0, P = 0.023), and sepsis (OR = 4.4, P < 0.001). CONCLUSION Abnormal coagulation profile was an independent predictor of morbidity and mortality in patients undergoing PLF. As such, it should be considered in preoperative optimization and risk stratification.
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Rembold SM, Santana RF, de Souza PA, Schwartz SMDOX. Nursing Diagnosis Risk for Delayed Surgical Recovery (00246): Concept Clarification and Definition of Empirical Referents. Int J Nurs Knowl 2017; 29:263-268. [PMID: 28544813 DOI: 10.1111/2047-3095.12176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/17/2017] [Accepted: 04/10/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE To clarify the concept of risk for delayed surgical recovery (00246) and to define the empirical referents for identification of predictive factors of delay in recovery. METHOD A concept analysis was developed based on the eight steps proposed by Walker and Avant. RESULTS Defining attributes were determined and antecedents and consequents identified. Cases were proposed cases and empirical referents established. CONCLUSION The results provided evidences and instrumentalize empirical referents, which may support an accurate nursing diagnosis. IMPLICATIONS FOR NURSING PRACTICE This clarification may contribute to the return to daily activities in a shortest time and promote surgical safety of the patient. OBJETIVOS Clarificar o conceito de risco de recuperação cirúrgica retardada (00246) e definir as referências empíricas para a identificação dos fatores preditores de atraso na recuperação. MÉTODO: Foi desenvolvida a análise de conceito desse fenômeno, com base nas oito etapas propostas por Walker e Avant. RESULTADOS Foram determinados os atributos definidores e identificados seus antecedentes e consequentes. Foram propostos casos e estabelecidas as referências empíricas. CONCLUSÕES: Os resultados proporcionaram evidências e instrumentalização das referências empíricas, o que pode auxiliar na acurácia do diagnóstico de enfermagem. IMPLICAÇÕES PARA A PRÁTICA DE ENFERMAGEM: Esta clarificação poderá contribuir para o retorno do paciente às atividades diárias em um tempo mais curto e promoção da segurança cirúrgica.
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Affiliation(s)
- Simone Martins Rembold
- Doctoral Student at the School of Nursing, Universidade Federal Fluminense (EEAAC, UFF), Niterói, Rio de Janeiro, Brazil.,EEAAC, UFF, Niterói, Rio de Janeiro, Brazil
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Practical Guidelines for Evaluating Transfusion Needs. Tech Orthop 2017. [DOI: 10.1097/bto.0000000000000204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kothari P, Somani S, Lee NJ, Guzman JZ, Leven DM, Skovrlj B, Steinberger J, Kim J, Cho SK. Thirty-Day Morbidity Associated with Pelvic Fixation in Adult Patients Undergoing Fusion for Spinal Deformity: A Propensity-Matched Analysis. Global Spine J 2017; 7:39-46. [PMID: 28451508 PMCID: PMC5400170 DOI: 10.1055/s-0036-1583946] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 03/24/2016] [Indexed: 01/28/2023] Open
Abstract
STUDY DESIGN Retrospective study of prospectively collected data. OBJECTIVE To determine if patients undergoing spinal deformity surgery with pelvic fixation are at an increased risk of morbidity. METHODS The American College of Surgeons National Surgical Quality Improvement Program is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from ~400 hospitals nationwide. Current Procedural Terminology codes were used to query the database between 2010 and 2014 for adults who underwent fusion for spinal deformity. Patients were separated into groups of those with and without pelvic fixation. Univariate analysis and multivariate logistic regression were used to analyze the effect of pelvic fixation on the incidence of postoperative morbidity and other surgical outcomes. RESULTS Multivariate analysis showed that pelvic fixation was a significant predictor of overall morbidity (odds ratio [OR] = 2.3, 95% confidence interval [CI]: 1.7 to 3.1, p = 0.0002), intra- or postoperative blood transfusion (OR = 2.3, 95% CI: 1.7 to 3.1 p < 0.0001), extended operative time (OR = 4.7, 95% CI: 3.1 to 7.0 p < 0.0001), and length of stay > 5 days (OR = 2.1, 95% CI 1.5 to 2.8, p < 0.0001) in patients undergoing fusion for spinal deformity. However, fusion to the pelvis did not lead to additional risk for other complications, including wound complications (p = 0.3191). CONCLUSION Adult patients undergoing spinal deformity surgery with pelvic fixation were not susceptible to increased morbidity beyond increased blood loss, greater operative time, and extended length of stay.
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Affiliation(s)
- Parth Kothari
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Sulaiman Somani
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Nathan J. Lee
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Javier Z. Guzman
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Dante M. Leven
- Department of Orthopaedic Surgery, SUNY Health Science Center at Brooklyn, Brooklyn, New York, United States
| | - Branko Skovrlj
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Jeremy Steinberger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Jun Kim
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Samuel K. Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States,Address for correspondence Samuel K. Cho, MD, Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, Box 1188, New York, NY 10029, United States (e-mail: ).
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Kong L, Liu Z, Meng F, Shen Y. Smoking and Risk of Surgical Site Infection after Spinal Surgery: A Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2016; 18:206-214. [PMID: 28004986 DOI: 10.1089/sur.2016.209] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The effect of smoking on the risk of surgical site infection (SSI) after spinal surgery remains controversial. Therefore, we conducted a meta-analysis to determine whether there is an association between smoking and the risk of SSI and to calculate the relative risk of infections attributable to smoking. METHODS We performed a literature search of cohort and case-control studies in the MEDLINE, Embase, and ISI Web of Science databases. Sensitivity and subgroup analyses were performed to test the robustness of overall estimates of risk and to investigate potential sources of heterogeneity. We further calculated the population-attributable fraction (PAF) to evaluate the proportion of SSIs associated with smoking. RESULTS In total, 26 independent observational studies involving 67,405 patients who underwent spinal surgery were analyzed. Smokers had a significantly higher risk of SSI than did nonsmokers (odds ratio [OR] 1.26; 95% confidence interval [CI] 1.05-1.51). Subgroup analysis according to the study design revealed an apparent association between smoking and SSI in the cohort subgroup (OR 1.40; 95% CI 1.17-1.66), but not in the case-control subgroup (OR 0.99; 95% CI 0.64-1.53). After evaluation of the PAF, the proportion of SSIs associated with smoking increased to 10.37%. CONCLUSIONS This meta-analysis demonstrated that smoking increases the risk of SSI after spinal surgery. False-negative associations in other studies may have resulted from defects in the study design. However, because of the heterogeneity among the studies in the present meta-analysis, the results should be interpreted with caution.
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Affiliation(s)
- Lingde Kong
- Department of Orthopedics, The Third Hospital of Hebei Medical University , Shijiazhuang, Hebei 050051, P.R. China
| | - Zhao Liu
- Department of Orthopedics, The Third Hospital of Hebei Medical University , Shijiazhuang, Hebei 050051, P.R. China
| | - Fei Meng
- Department of Orthopedics, The Third Hospital of Hebei Medical University , Shijiazhuang, Hebei 050051, P.R. China
| | - Yong Shen
- Department of Orthopedics, The Third Hospital of Hebei Medical University , Shijiazhuang, Hebei 050051, P.R. China
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Love KL. Patient Care Interventions to Reduce the Risk of Surgical Site Infections. AORN J 2016; 104:506-515. [DOI: 10.1016/j.aorn.2016.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 10/04/2016] [Indexed: 01/28/2023]
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Complications and Mortality After Lumbar Spinal Fusion in Elderly Patients With Late Stage Renal Disease. Spine (Phila Pa 1976) 2016; 41:E1298-E1302. [PMID: 27054452 DOI: 10.1097/brs.0000000000001618] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective database review. OBJECTIVE To assess complication and mortality rates after lumbar spinal fusion surgery in patients with late stage renal disease. SUMMARY OF BACKGROUND DATA Lumbar spinal fusion surgeries are common in elderly patients who are well-known to have increased comorbidity burden. Elderly patients with severe chronic kidney disease (CKD) represent a population with poorly understood mortality and complication rates after spine surgery. METHODS Medicare data from the PearlDiver Database (2005-2012) was queried for patients who underwent primary 1-2 level posterolateral lumbar spine fusion surgeries. This cohort was divided into two study groups: a cohort with a preexisting diagnosis of late stage renal disease (N = 1654) and a control cohort of all other patients (N = 242,085). The control group was matched to the renal disease cohort by age, sex, and comorbidities. Moreover, 90-day complication rates and 90-day and 1-year mortality were assessed. RESULTS The renal disease cohort had increased rates of all medical complications (21.3 vs. 14.2%; odds ratio, OR, 1.64; 95% confidence intervals, CI, 1.44 -1.85; P < 0.0001). Increased rates of infection (4.4 vs. 1.8%; OR 2.43; 95% CI 1.87 - 3.16; P < 0.0001) and procedure-day blood transfusions (20.7 vs. 14.7%; OR 1.51; 95% CI 1.33 - 1.72; P < 0.0001) were also observed in the renal disease cohort. Both 90-day (1.1 vs. 0.2%; OR 5.05; 95% CI 2.90-8.77; P < 0.0001) and 1-year mortality (1.9 vs. 0.7%; OR 2.77; 95% CI 1.87-4.11; P < 0.0001) were significantly higher in the renal disease group compared with the control group. CONCLUSION Elderly patients with late-stage renal disease treated with 1-2 level posterolateral lumbar fusion have 1.6 times increased odds of experiencing a major medical complication within 3 months of surgery and 2.8 times increased odds of 1-year mortality when compared with matched controls. LEVEL OF EVIDENCE 3.
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Boniello AJ, Verma K, Peters A, Lonner BS, Errico T. Pre-Operative Autologous Blood Donation Does Not Affect Pre-Incision Hematocrit in Adolescent Idiopathic Scoliosis Patients. A Retrospective Cohort of a Prospective Randomized Trial. Int J Spine Surg 2016; 10:27. [PMID: 27652198 DOI: 10.14444/3027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Pre-donation of autologous blood prior to spine fusion for adolescent idiopathic scoliosis (AIS) has been used in deformity surgery. The effect of pre-donation on pre-operative hematocrit (Hct) remains debated. Multiple factors may influence pre-operative Hct including intravascular volume status, patient factors, and timing of pre-operative blood donation. The purpose of this study was to determine if pre-donation significantly lowers pre-incision Hct in AIS patients. METHODS A retrospective cohort study of a Level-1 prospective randomized trial was conducted. 125 patients from the homogeneous population were included. AIS patients undergoing a posterior only spinal fusion for AIS were separated into two groups based on their pre-operative blood donation history. Demographic variables, pre-incision Hct, and transfusion rates were compared between the two groups using the Student's T-test. RESULTS Pre-donation and non pre-donation groups had 28 and 97 patients, respectively. Pre-donation group was 75% female (21F, 7M) and non pre-donation group was 78% female (76F, 21M). There was no difference between pre-donation and non pre-donation groups in mean age (15.6 ± 2.2 vs 14.8 ± 2.2, p = 0.081), BMI (23.1 ± 4.2 vs 21.7 ± 5.3, p = 0.219), and pre-incision Hct (32.8 ± 3.4 vs 33.8 ± 3.1, p = 0.628). The overall transfusion rates were equivalent (32.1± 48.0% vs 25.8 ± 44.0%, p = 0.509), however, the rate of allogenic transfusion for the pre-donation group was significantly lower (3.6 ± 18.9% vs 25.8 ± 44.0%, p = 0.011). CONCLUSIONS This study supports the use of pre-donation for AIS, without a significant drop in pre-incision Hct. Patients that donate are also much less likely to be exposed to allogenic blood. There may be a surgeon bias to recommend pre-donation in patients with a larger BMI and older age. Future studies are needed from a larger population of patients including those with non-AIS pathology. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Anthony J Boniello
- Division of Spinal Surgery, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY; Department of Orthopaedic Surgery, Drexel College of Medicine, Hahnemann University Hospital, Philadelphia, PA
| | - Kushagra Verma
- Division of Spinal Surgery, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY; Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA
| | - Austin Peters
- Division of Spinal Surgery, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
| | - Baron S Lonner
- Department of Orthopaedic Surgery, Mount Sinai Beth Israel, New York, New York
| | - Thomas Errico
- Division of Spinal Surgery, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
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Borden TC, Bellaire LL, Fletcher ND. Improving perioperative care for adolescent idiopathic scoliosis patients: the impact of a multidisciplinary care approach. J Multidiscip Healthc 2016; 9:435-445. [PMID: 27695340 PMCID: PMC5028162 DOI: 10.2147/jmdh.s95319] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The complex nature of the surgical treatment of adolescent idiopathic scoliosis (AIS) requires a wide variety of health care providers. A well-coordinated, multidisciplinary team approach to the care of these patients is essential for providing high-quality care. This review offers an up-to-date overview of the numerous interventions and safety measures for improving outcomes after AIS surgery throughout the perioperative phases of care. Reducing the risk of potentially devastating and costly complications after AIS surgery is the responsibility of every single member of the health care team. Specifically, this review will focus on the perioperative measures for preventing surgical site infections, reducing the risk of neurologic injury, minimizing surgical blood loss, and preventing postoperative complications. Also, the review will highlight the postoperative protocols that emphasize early mobilization and accelerated discharge.
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Affiliation(s)
- Timothy C Borden
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | - Laura L Bellaire
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
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Impact of Resident Involvement on Morbidity in Adult Patients Undergoing Fusion for Spinal Deformity. Spine (Phila Pa 1976) 2016; 41:1296-1302. [PMID: 26909839 DOI: 10.1097/brs.0000000000001522] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective study of prospectively collected data. OBJECTIVE The aim of this study was to determine whether patients undergoing spinal deformity surgery with resident involvement are at an increased risk of morbidity. SUMMARY OF BACKGROUND DATA Resident involvement has been investigated in other orthopedic procedures but has not been studied in adult spinal deformity surgery. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current procedural terminology (CPT) codes were used to query the database for adults who underwent fusion for spinal deformity between 2005 and 2012. Patients were separated into propensity score matched groups of those with and without resident involvement. Univariate analysis and multivariate logistic regression were used to analyze the effect of resident involvement on the incidence of postoperative morbidity and other surgical outcomes. RESULTS Resident involvement was an independent predictor of overall morbidity [odds ratio (OR) 2.2, P < 0.0001], wound complication (OR 2.5, P = 0.0252), intra-/postoperative transfusion (OR 2.3, P < 0.0001), and length of stay > 5 days (OR 2.0, P < 0.0001). However, resident involvement was not an independent predictor for other complications, such as mortality. CONCLUSION Resident participation was associated with significantly longer operative times. As a result, higher rate of certain morbidity, but not mortality, was found, specifically for complications that have been previously associated with long operative duration. LEVEL OF EVIDENCE 3.
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Abstract
STUDY DESIGN Retrospective study of prospectively collected data. OBJECTIVE To determine if postoperative morbidity for patients undergoing spinal deformity surgery varies by sex. SUMMARY OF BACKGROUND DATA Influence of sex has been investigated in other surgical procedures but has not yet been studied in adult spinal deformity surgery. METHODS The American College of Surgeons National Surgical Quality Improvement Program is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent fusion for spinal deformity. Patients were separated into groups of male and female sex. Univariate analysis and multivariate logistic regression were used to analyze the effect of sex on the incidence of postoperative morbidity and mortality. RESULTS Female sex was found to be a predictor of any complication[odds ratio (OR): 1.4, 95% confidence interval (CI) 1.2-1.7, P < 0.0001], intra- or postoperative RBC transfusion (OR: 1.6, 95% CI 1.4-1.9, P < .0001), urinary tract infection (OR: 2.0, 95% CI 1.2-3.3, P = 0.0046), and length of stay >5 days (OR: 1.3, 95% CI 1.1-1.5, P = 0.0015). Male sex was associated with higher rate of pulmonary (2.9% vs. 2.0%, P = 0.0344) and cardiac complications (0.9% vs. 0.5%, P = 0.0497). However, male sex as an independent risk factor for pulmonary (OR: 1.4, 95% CI 1.0-2.1, P = 0.0715) and cardiac complications (OR: 1.9, 95% CI 0.9-4.0, P = 0.1076) did not reach significance. CONCLUSION Female sex was found to increase overall morbidity, particularly for urinary tract infection, transfusion, and length of stay >5 days. Male sex was associated with greater incidence of pulmonary and cardiac complications. Thus, sex and other patient characteristics highlighted must be considered as part of surgical risk planning and patient counseling. LEVEL OF EVIDENCE 3.
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Jackson KL, Devine JG. The Effects of Obesity on Spine Surgery: A Systematic Review of the Literature. Global Spine J 2016; 6:394-400. [PMID: 27190743 PMCID: PMC4868585 DOI: 10.1055/s-0035-1570750] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 11/11/2015] [Indexed: 12/12/2022] Open
Abstract
Study Design Literature review. Objective The aim of this literature review is to examine the effects of obesity on postoperative complications and functional outcomes after spine surgery. Methods A review of the relevant literature examining the effects of obesity and spine surgery was conducted using PubMed, Google Scholar, and Cochrane databases. Results Obesity contributes to disk degeneration and low back pain and potentially increases the risk of developing operative pathology. Obese patients undergoing spine surgery have a higher risk of developing postoperative complications, particularly surgical site infection and venous thromboembolism. Though functional outcomes in this population may not mirror the general population, the treatment effect associated with surgery is at least equivalent if not better in obese individuals. This reduction is primarily due to worse outcomes associated with nonoperative treatment in the obese population. Conclusion Obese individuals represent a unique patient population with respect to nonoperative treatment, postoperative complication rates, and functional outcomes. However, given the equivalent or greater treatment effect of surgery, this comorbidity should not prohibit obese patients from undergoing operative intervention. Future investigations in this area should attempt to develop strategies to minimize complications and improve outcomes in obese individuals and also examine the role of controlled weight loss preoperatively to mitigate these risks.
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Affiliation(s)
- Keith L. Jackson
- Department of Orthopaedics and Rehabilitation, Womack Army Medical Center, Fort Bragg, North Carolina, United States,Address for correspondence Keith L. Jackson II, MD Staff Spine Surgeon, Department of Orthopaedics and RehabilitationWomack Army Medical Center, 2817 Reilly Road, Fort Bragg, NC 28310United States
| | - John G. Devine
- Department of Orthopaedic Surgery, Georgia Regents University, Augusta, Georgia, United States
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Kato S, Chikuda H, Ohya J, Oichi T, Matsui H, Fushimi K, Takeshita K, Tanaka S, Yasunaga H. Risk of infectious complications associated with blood transfusion in elective spinal surgery-a propensity score matched analysis. Spine J 2016; 16:55-60. [PMID: 26499767 DOI: 10.1016/j.spinee.2015.10.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 08/10/2015] [Accepted: 10/12/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Although the negative aspects of blood transfusion are increasingly recognized, less is known about transfusion-related risks in spinal surgery. PURPOSE This study was designed to determine whether perioperative allogeneic blood transfusion is associated with increased risk of infectious complications after elective spinal surgery. STUDY DESIGN A retrospective cohort study with propensity score matched analysis was carried out. PATIENT SAMPLE Data of patients with spinal canal stenosis and spondylolisthesis who underwent elective lumbar surgeries (decompression or fusion) were obtained from the Diagnosis Procedure Combination database, a nationwide administrative inpatient database in Japan. OUTCOME MEASURES Clinical outcomes included in-hospital death and the occurrence of infectious complications (surgical site infection [SSI], respiratory tract infection, urinary tract infection, and sepsis). METHODS Patients' clinical information, including sex, age, type of hospital, preoperative comorbidities, duration of anesthesia, cell saver use, and volume of allogeneic blood transfused, were investigated. Patients transfused with >840 mL (6 units) were excluded. Propensity scores for receiving transfusion were calculated, with one-to-one matching based on estimated propensity scores to adjust for patients' baseline characteristics. The proportions of complications were compared in patients with and without transfusions. This study was funded by grants from the Ministry of Health, Labour and Welfare, Japan. RESULTS Of the 84,650 patients identified, 5,289 patients (6.1%) received transfusions, with 4,436 (5.2%) receiving up to 840 mL. One-to-one propensity score matching resulted in 4,275 pairs with and without transfusion. Patients transfused were at increased risk of SSI (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.4-2.5; p<.001) and urinary tract infection (OR, 2.5; 95% CI, 1.5-4.2; p<.001) than those not transfused. CONCLUSIONS Allogeneic blood transfusion after elective lumbar surgery was associated with increased risks of SSI and urinary tract infection.
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Affiliation(s)
- So Kato
- Department of Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Hirotaka Chikuda
- Department of Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Junichi Ohya
- Department of Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takeshi Oichi
- Department of Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Katsushi Takeshita
- Department of Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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Risk factors for surgical site infections following spinal surgery. J Clin Neurosci 2015; 22:1862-6. [DOI: 10.1016/j.jocn.2015.03.065] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 03/16/2015] [Accepted: 03/21/2015] [Indexed: 01/11/2023]
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